Uterine Disorders- Dobbs Flashcards
Leiomyoma (Uterine Fibroid):
- how common?
- Describe
-Common, benign uterine tumor
=Discrete, round, firm, often multiple uterine tumor composed of smooth muscle and connective tissue
Leiomyoma aka fibroids depend on ______
estrogen
Fibroids classified by location: (list types)
subserous, intramural, submucous, intraligamentous, pedunculated, parasitic (blood supply from an organ to which it becomes attached), and cervical
Uterine Fibroid:
-clinical features:
Asymptomatic
Firm, enlarged, irregular uterine mass
Pressure or fullness in pelvis
Menorrhagia, metrorrhagia, intermenstrual bleeding, and dysmenorrhea common
Uterine Fibroid:
-What is the MC presenting symptom?
bleeding
Other Sx associated with uterine fibroid
- Anemia
- Infertility may be due to a myoma that significantly distorts the uterine cavity
Uterine Fibroid:
Diagnosis: (hint: several choices)
Pelvic ultrasound D&C Saline Hysteroscopy Hysterosalpingography Laparoscopy Pelvic MRI/CT
Uterine Fibroid:
-Tx?
- Observation
- Symptomatic patients may have myomectomy or D&C
- Depo-provera (medroxyprogesterone acetate)150mg IM every 28 days or Danazol (synthetic modified testosterone) 400-800 mg daily can be used to help stop bleeding – usually treat anemia prior to surgery
- Uterine arterial embolization or endometrial ablation (no desire for future fertility)
Uterine Fibroid:
-what is the final step?
hysterectomy
Endometriosis= a condition where the endometrial tissue is found ______
outside of endometrial cavity
Common location for ectopic endometrial tissue:
- Ovaries
- Uterosacral ligament
- GI tract
- May also be as distant as lungs and brain
Endometriosis Epidemiology :
-exact prevalence is _____
-unknown because surgery is required for dx
Endometriosis:
-usually occurs in women of _________
**reproductive age–20’s-30’s
Endometriosis:
-is found in ___% of infertile women
25%
Endometriosis:
Smallest (earliest) implants are ______
red, petechial lesions on peritoneal surface
Endometriosis:
-describe older lesions
Dark brown, blue or black implants are older filled with menstrual debris (powder burn lesions) – can reach 5-10 mm
-Surrounding tissue is thickened and scarred
-Adhesions develop
Endometriosis:
Describe Cysts on ovaries
called endometriomas or “chocolate cysts”
Endometriosis:
-Cysts grow to ____cm in size
several cm
Endometriosis:
Erodes into underlying tissue and distorts remaining organs with ______
implants
List the 3 theories of endometriosis:
- Retrograde menstruation- reflux of endometrial cells
- Vascular and lymphatic dissemination
- Transformation of peritoneal cells
Other theories of endometriosis:
-Genetic influences have been considered
-
Endometriosis:
-___% of endometriosis Pts’ first-degree female relatives are diagnosed with the disease
7-9%
Endometriosis:
-possible role for _____ allele
HLA-B7
Endometriosis:
-suspicion based on history, Sx, and ______
physical exam, lab or imaging information – infertility, dysmenorrhea, and dyspareunia
-Endometrial implants and cysts respond to the hormonal fluctuations of the menstrual cycle
Endometriosis:
-List the 3 D’s
**Dysmenorrhea, Dyspareunia, Dyschezia
Dyspareunia=
painful intercourse
Dyschezia=
constipation associated with a defective reflex for defecation
Dysmenorrhea=
painful menstruation
Endometriosis diagnosis is based on:
tissue biopsy with laproscopy
Endometriosis;
women may be asymptomatic or may have severe ______
pelvic pain
T/F: Infertility is common with endometriosis
true
Endometriosis:
-increased risk:
- Family hx
- Early menarche
- Long duration of menstrual flow
- Heavy bleeding during menses
- Shorter cycles
Decreased risk for endometriosis:
> 4 hr/wk exercise, higher parity, longer duration of lactation
Endometrial DDx:
PID Pelvic adhesions Gastrointestinal dysfunction Dysmenorrhea Ovarian cysts Ectopic pregnancy Adnexal torsion -Rupture of corpus luteum cyst or ovarian neoplasm
Endometriosis Clinical Features :
-may present w/ dysmenorrhea, _______, _______ (difficulty passing bowel movements), intermittent spotting, pelvic pain, and infertility
dysmenorrhea, dyspareunia, dyschezia
Endometriosis Clinical Features :
stimulated by hormones, and implants grow ______
large and may undergo secretory change and bleed
Endometriosis:
Pain comes from pressure and _______ within and around the lesions, traction on adhesions, and number of implants and proximity to nerves
inflammation
-Severe pain associated with deeply infiltrating lesions
Endometriosis:
-On Physical exam:
- Tender nodules in posterior vaginal fornix
- Pain with uterine motion
- Tender adnexal masses
- None
endometriosis:
-diagnosis of endometriosis is substantiated by direct visualization of _______
implants during laparoscopy or laparotomy and tissue biopsy
endometriosis: diagnosis
- histological _______
findings
Endometriosis: tx
- Depends on severity of symptoms, location of disease, and desire for childbearing
- Expectant (watch and wait)
- NSAIDs for discomfort
- Surgery may be conservative or definitive (may remove large endometriomas)
- Medica tx
Endometriosis:
describe medical treatment
- Oral contraceptives (progesterone)
- IUD
- Progesterone therapy (Depo Provera or Mirena)
- Danazol (19–nortestosterone derivative)
- GnRH agonists (Lupron)
Pregnancy and Endometriosis:
-can pregnancy improve or worsen endometriosis?
- Pregnancy may temporarily improve or worsen endometriosis symptoms
- Pregnancy does not cure endometriosis
Adenomyosis Clinical Features:
Asymptomatic Severe dysmenorrhea Abdominal pressure and bloating Symmetrically enlarged uterus Heavy bleeding
Adenomyosis:
- the classic patient is middle aged, severe ______, hx of ______
dysmenorrhea, history of childbearing, symmetrically enlarged uterus, and menorrhagia
Adenomyosis Diagnosis:
- Pelvic US
- MRI
- Hysterectomy is definitive diagnosis
Adenomyosis tx:
NSAIDs
Hormones
Hysterectomy
cystocele=
= bladder prolapse (aka wall between the bladder and vagina weakens)
Common for bladder and _____ to prolapse together, called ______
- **bladder & urethra
- called Cystourethrocele (=MC type of prolapse)!!
Rectocele=
prolapse of rectum or large bowel
Uterine Prolapse= the uterus can be sen ______
- *descending into the vagina
- cervix is clearly visible at vaginal introitus
Uterine Prolapse:
-typically occurs after_____
pregnancy, labor, and vaginal delivery but also may occur in patients without children
Uterine Prolapse:
-Risk increases to ___% after menopause for all women
50%
-More common in white women
Uterine Prolapse:
-also common with any condition that increases intra-abdominal pressure–including:
obesity, chronic cough (asthma or COPD), heavy lifting, pelvic tumors, ascites, or constipation increase risk
Uterine Prolapse: Clinical Features (list)
- Sx are usually worse after prolonged standing (gravity)!
- May be relieved by lying down
- Vaginal fullness
- Lower abdominal pain
- Low back pain
- **“Falling out sensation”
- May also have cystocele, rectocele, or enterocele
Uterine Prolapse Grading:
Grade 0=
No prolapse (normal)
Uterine Prolapse Grading:
Grade 1=
Descent is >1cm above hymen
Uterine Prolapse Grading:
Grade 2=
Descent to hymen
Uterine Prolapse Grading:
Grade 3=
– Protrudes, but no less than 2cm total vaginal length
Uterine Prolapse Grading:
-grade 4=
Total eversion of lower genital tract
Uterine Prolapse Management:
- referral?
- non-surgical approaches include:
- Refer to GYN!
- Non-surgical: weight reduction, smoking cessation, pelvic muscle exercises, and use of a vaginal pessary
- Surgical approach
Abnormal uterine bleeding includes:
abnormal menstrual bleeding and bleeding due to other causes such as pregnancy, systemic disease, or cancer.
Exclusion of all possible pathologic causes of AUB establishes the diagnosis of _______
dysfunctional uterine bleeding.
**In general, DUB is correlated with endocrine dysfunction
AUB:
Bleeding in any of the following situations is abnormal: (list)
Bleeding between periods Bleeding after intercourse Spotting anytime in menstrual cycle Bleeding heavier or for more days than normal Bleeding after menopause
AUB can occur at any ___
age
AUB: why is it difficult to dx/manage?
- Diagnosis and management of AUB present some of the most difficult problems in gynecology
- Patient may not be able to localize source of bleeding
- NOTE: **more than one cause may be present such as fibroids and cancer
AUB:
In child-bearing women, a complication of ______ must be considered
** pregnancy
Menorrhagia=
Hypomenorrhea=
Regular interval between periods, excessive flow and duration
Decreased flow during normal duration of regular period
Metrorrhagia=
Irregular intervals of menses, excessive flow and duration
Polymenorrhea=
Shortened interval between periods , < 19-21 day interval
Menometrorrhagia=
Irregular or excessive bleeding during periods and between periods
Oligomenorrhea=
Lengthened interval between periods, > 35 days intervals
AUB Causes:
Pregnancy Miscarriage Ectopic pregnancy Adenomyosis Birth control (IUDs or OCPs)
Hormones STIs Fibroids Clotting disorders Polyps Endometrial hyperplasia Cancer
Causes of AUB:
-Structural causes: PALM
**Polyp
Adenomyosis
Leiomyoma
Malignancy & hyperplasia
Causes of AUB:
-nonstructural causes: COEIN
Coagulopathy Ovarian dysfunction Endometrial process Iatrogenic Not yet classified
Evaluation of AUB
- Note amount of menstrual flow
- Menstrual period length and amount
- Note LMP, LNMP
- Age at menarche & menopause
- Medication taken, Supplements/herbs
- Systemic disease (renal, adrenal, hepatic, or thyroid)
- Episodes of intermenstrual bleeding
- Changes in general health
- Pt to keep record of bleeding patterns - differentiate abnormal & variation of normal
- Abdominal pain
- Dyspareunia
- Galactorrhea
- Hirsutism, acne
- Weight gain
- Petechiae, ecchymosis
- Pallor
Eval of AUB:
-PE?
- **Pelvic exam and abdominal exam
- Look for masses
- Symmetrically enlarged uterus most typical with Adenomyosis
- Enlarged, irregular uterus consider leiomyoma
- Atrophic & inflammatory vulvar and vaginal lesions can be visualized
- Cervical polyps and invasive lesions
- Rectovaginal exam is especially important- palpate uterus
AUB Work-Up:
- Lab tests?
- Additional tests?
- History and Physical
- Lab tests – CBC, bHCG, TSH, HbA1C, STI testing
-Additional tests – Pap smear,
pelvic US, endometrial biopsy, hysteroscopy, D&C, consider CT or MRI of abdomen and pelvis
-**Refer to OB-GYN
Recommendations for AUB:
- First consider the situation/age
- -Adolescent
- -19-39 yo
- -and >___yo
40
EVALUATION OF AUB:
Cytological exam
- Pap smears can help screen for cervical dysplasia – BUT Not reliable for diagnosis of endometrial abnormalities
- Endometrial cells in a postmenopausal women abnormal on PAP
Other evaluation tools:
- Endometrial tissue biopsy
- Transvaginal ultrasound
- Hysteroscopy
Describe Hysteroscopy and why is it important in eval of pathology in the uterine cavity?
- Direct visualization of the endometrium via camera into endometrial cavity with immediate biopsy. Done as outpatient.
- ** Gold standard for evaluation of pathology in the uterine cavity**
PELVIC ULTRASOUND
- Has become an integral part of the gynecological pelvic exam
- Scan done transabdominally or transvaginally
- **Transvaginal U/S with empty bladder gives greater details of pelvic organs
- Transabdominal U/S performed with full bladder, enables a wider but less discriminative exam of pelvis
AUB – Endometrial Biopsy
- Use of a curette, cervical dilation not always needed
- Small samples of tissue removed from the endometrium
- Samples are looked at under a microscope to identify abnormal cells
- Tissue obtained sometimes may be inadequate for dx so hysteroscopy or D&C must be performed
D & C - Dilatation and Curettage (describe)
=a procedure to remove tissue from inside the uterus.
-Procedure used to dx and treat certain uterine conditions such as heavy bleeding or to clear the uterine lining after a miscarriage or abortion.
-Done under local anesthesia, almost always in an outpatient or ambulatory surgical setting.
Treatment of AUB:
-primary goal=
- Determine underlying cause
- Resume regular shedding of the endometrium
- Regulation of uterine bleeding
- **Rule out cancer
Treatment of AUB:
-Progesterone->
Progesterone agent – Depo injections or IUD may be helpful in some cases
Treatment of AUB:
OCPs–>
- Suppresses the endometrium
- Established regular predictable withdrawal cycle
Treatment of AUB:
-surgical?
Endometrial ablation, surgical management, or hysterectomy
Postmenopausal bleeding is defined as bleeding that occurs after _____
**12 months of amenorrhea in a middle-aged woman
What lab value (level) is very helpful for postmenopausal bleeding?? (KNOW)
- FSH levels are particularly helpful in the differential diagnosis of menopause verses hypothalamic amenorrhea.
- **A FSH > 30mIU/mL is highly suggestive of menopause and estradiol below 20.
Postmenopausal bleeding is more likely to be caused by ______ _______ than is bleeding in younger women, and MUST ALWAYS BE INVESTIGATED
**pathologic disease
Neither normal (functional) bleeding or _____ _____ should occur after menopause
abnormal bleeding
Postmenopausal bleeding:
-MC cause=
**the use of exogenous hormones.
KNOW!!
Postmenopausal bleeding:
-what is vital for Pts?
Careful history taking becomes vital since patients may not follow specific instructions on the use of estrogens and progesterone therapy
Endometrial Cancer:
-how common?
Demographic?
-Peak incidence=
- **MC GYN cancer
- Postmenopausal women make-up ~75% of cases (MC in white females)
-Peak incidence of onset is in 7th decade
Endometrial CA:
- what provides a protective effect?
- what increases risk?
OCPs (combined estrogen and progesterone) have protective effect
-exposure to unopposed estrogen increases risk
Endometrial CA:
-MC type=
Adenocarcinoma is the MC type, ~80% of cases of endometrial carcinoma in US
Endometrial Cancer Risk Factors:
Increasing age Obesity Nulliparity/Infertility Late menopause Early menarche Diabetes Unopposed estrogen Genetic predisposition Prior pelvic radiation
Endometrial Cancer Clinical Features:
-cardinal Sx=
- *Cardinal symptom is abnormal uterine bleeding
- Abnormal vaginal discharge
- Intermittent spotting
- Lower abdominal cramps and pain
Endometrial Cancer:
-List the 4 routes of endometrial CA spread
- Direct Extension
- Lymphatic mets
- Peritoneal implants after transtubal spread
- Hematogenous spread
Endometrial Cancer Diagnosis:
- Incidental on Pap Smear
- Pelvic ultrasound
- Dilation and curettage
- Endometrial biopsy
- **REFER TO GYN!
Endometrial Cancer Management:
- **Refer to GYN!
- Total hysterectomy combined with salpingo-oophorectomy (basis of treatment and staging)
- Radiation
- Chemotherapy
